Recurring concern

Failure to provide adequate supervision and emergency assistance coverage at recreational activity venues

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First reported 14 Sep 2015•Latest report 5 Feb 2025

Definition

What this concern includes

Includes failures of dedicated participant-supervision and immediate-assistance arrangements at recreational activity venues, including inadequate coverage, absent or ineffective supervision, poor visibility or presence of supervisors, and insufficient capability to recognise and respond promptly to medical problems or incidents.

Not included

  • Excludes generic staffing, first-aid training, risk-assessment or regulatory deficiencies unless they directly result in inadequate venue supervision or emergency-assistance coverage.
  • Excludes clinical care or emergency-service response after appropriate venue supervision and assistance arrangements have operated effectively.
  • Excludes supervision of patients, prisoners, residents or employees outside recreational activity venues.
  • Excludes hazards arising solely from venue design, equipment, participant suitability or activity rules where no supervision or immediate-assistance deficiency is identified.
Reports
4

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2015–2025

First to latest report issue date

Stated actions
4

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department for Digital, Culture, Media and Sport1
Department for Transport1
DW Fitness First1
Health and Safety Executive1
National Coasteering Charter1
ukactive1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Somerset

    AI-generated summary

    Simon Timothy Harding · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Simon Timothy Harding died after becoming separated from his motocross bike during a jump at Granfield Moto-Cross Track on 10 September 2022; the bike landed on his head, causing catastrophic and unsurvivable head injuries. Concerns included limited rider registration, no safety briefing, inadequate track regulation and stewarding, lack of rider segregation, and no first-aid training for venue staff. The report also identified a lack of mandatory minimum safety and risk-management standards for motocross venues as a risk of future deaths.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient and ineffective track steward coverage for immediate assistance

    Wider context from the report

    “(a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics or other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information. (b) There did not appear to be any kind of safety briefing for the riders before using the Track. (c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike. (d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track. (e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived. Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity. It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a risk of future deaths. ”

    Source location

    Simon Timothy Harding · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Responsibility for concerns about a racetrack bike crash lies with DCMS rather than the Department for Transport.

    Verbatim wording from the response

    “Our officials have advised that the matters of concerns raised would not be appropriate for DfT to respond but is for DCMS, as the bike crash happened on a racetrack and not on the public highway.”

    Source location

    Response from Department for Transport
    Page 1 · response
    Published 6 February 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Individual motor sport event organisers are responsible for protecting participants’ safety and wellbeing.

    Verbatim wording from the response

    “The safety and wellbeing of everyone taking part in sport is absolutely paramount. There will always be risks associated with participating in motor sports, but it is important that robust measures are in place to reduce the risk of major injuries and health issues. It is the responsibility of individual motor sport event organisers to ensure that they protect the safety and wellbeing of their participants.”

    Source location

    Response from Department for Culture, Media and Sport
    Page 1 · response
    Published 6 February 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Event and venue operators have workplace health and safety duties under HSWA and associated regulations.

    Verbatim wording from the response

    “Regardless of whether an event is regulated or authorised by a governing body, it is important to be clear that health and safety laws apply. The Health and Safety Executive (HSE) applies workplace health and safety law in relation to those with duties under the Health and Safety at”

    Source location

    Response from Department for Culture, Media and Sport
    Page 1 · response
    Published 6 February 2025

    Open published response

  2. Dorset

    AI-generated summary

    Iain Richard Farrell · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Iain Richard Farrell became breathless and exhausted during a led coasteering activity on 26 May 2019, was swept back into the sea by a large wave after reaching a ledge, and was later confirmed deceased despite resuscitation efforts. The principal concerns were the risks of lone guiding, the delayed access to the sole means of communication, and the absence of assessment of participants’ swimming ability and physical fitness during booking.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure adequate guide staffing for coasteering groups

    Wider context from the report

    “ii. Given the risks associated with lone guiding, consideration should be given to the NCC guidance promoting that two guides should be the minimum allocated to any coasteering group. Where a provider departs from the guidance and allocates a single guide, they should be directed to ensure they can demonstrate additional safety measures they have adopted to mitigate the risks associated with lone guiding, including but not limited to how the safety needs of the participants are met if the guide becomes incapacitated, or if a participant becomes incapacitated requiring the full attention of the guide. ”

    Source location

    Iain Richard Farrell · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Produce a final updated Safety Advice for Coasteering Providers document incorporating consultation responses and advice.

    Verbatim wording from the response

    “The current NCC document, ‘Safety Advice for Coasteering Providers 2015 Version 3’ will be updated to address the 4 points raised as concerns by the Coroner in Section 5.2 i-iv in the Prevention of Future Deaths report. The rewrite will also update the 2015 version with other practices and advice that may have changed since the writing of the original advice with an aim of continuing to promote safe coasteering.”

    Source location

    Response from National Coasteering Charter
    Page 1 · response
    Published 1 November 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Consult NCC members by email and through a committee-led working group on updates to the Safety Advice for Coasteering Providers document.

    Verbatim wording from the response

    “The current NCC document, ‘Safety Advice for Coasteering Providers 2015 Version 3’ will be updated to address the 4 points raised as concerns by the Coroner in Section 5.2 i-iv in the Prevention of Future Deaths report. The rewrite will also update the 2015 version with other practices and advice that may have changed since the writing of the original advice with an aim of continuing to promote safe coasteering.”

    Source location

    Response from NCC
    Page 1 · response
    Published 1 November 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Produce a final updated Safety Advice for Coasteering Providers document incorporating member consultation responses and advice.

    Verbatim wording from the response

    “The current NCC document, ‘Safety Advice for Coasteering Providers 2015 Version 3’ will be updated to address the 4 points raised as concerns by the Coroner in Section 5.2 i-iv in the Prevention of Future Deaths report. The rewrite will also update the 2015 version with other practices and advice that may have changed since the writing of the original advice with an aim of continuing to promote safe coasteering.”

    Source location

    Response from NCC
    Page 1 · response
    Published 1 November 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Add key learning points from the report to the NCC Guide Award through updates to Guide Award providers.

    Verbatim wording from the response

    “Action Item | How | When Provided NCC members with the information in the report | This will be shared with members at our AGM | 16th November 2023, (completed) Consultation with our membership regarding the Updates to the document ‘Safety Advice for Coasteering Providers’ | Via email and a working group led by the committee. | Consultation to start January 2024 Produce an updated final version of the document ‘Safety Advice for Coasteering Providers’ | Committee working group taking on responses and consultation advice from members | 1st March 2024 Provide updates to members ahead of the 2024 season on the changes made | Via regional representative meetings | March - April 2024 (Start of season) Add key learning points to our NCC Guide Award | Via updates to our Guide Award Providers | March - April 2024 (Start of season)”

    Source location

    Response from NCC
    Page 1 · response
    Published 1 November 2023

    Open published response

  3. Inner North London

    AI-generated summary

    Catherine Mary GIBBON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Catherine Mary Gibbon suffered a seizure while swimming at a gym on 1 June 2018 and remained face down in the water for around ten minutes. She sustained a hypoxic-ischaemic brain injury following non-fatal drowning and died. Concerns included inadequate pool monitoring and CCTV arrangements, a broken camera, insufficient staff training and emergency equipment, and gaps in first-aid certification systems.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate CCTV screen visibility for pool activity

    Wider context from the report

    “4. The receptionist also gave evidence that in her opinion, the screens (the monitor was split into four screens for the four cameras) were too small to see the pool activity clearly. ”

    Source location

    Catherine Mary GIBBON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Absence of immediate poolside telephone access for summoning medical assistance

    Wider context from the report

    “7. There was no landline at poolside that could be used to call an ambulance in case of emergency, to enable medical assistance to be summoned immediately by someone who actually had sight of the casualty. ”

    Source location

    Catherine Mary GIBBON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Suffolk

    AI-generated summary

    ANTHONY STEPHEN CLEVELAND · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Anthony Stephen Cleveland collapsed after exercising unsupervised at a gym on 11 June 2013 and died some days later in intensive care following a cardiac arrest and hypoxic injury associated with severe coronary artery stenosis. Concerns included inadequate supervision and resuscitation, inadequate risk assessment, a lack of qualified first aiders, and the absence of formalised national guidance for risk assessment in fitness centres and gyms.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient supervision for immediate recognition of medical problems

    Wider context from the report

    “It is possible and entirely foreseeable that significant medical problems may arise in an environment where people are exercising and may have underlying medical problems that could predispose them to collapse. Given the severity of the underlying coronary artery disease and subsequent cardiac arrest here it is not possible to say in this particular situation whether this tragic outcome could have been avoided with an earlier and more effective response, but the evidence here was that there was not a level of supervision that enabled the problem to be recognised immediately, and neither was there an adequate attempt to resuscitate once it had been established that a person had collapsed. There was also evidence of absence of adequate risk assessment in respect of gym users, a lack of qualified first aiders, and an absence of formalised national guidance on risk assessment in fitness centres and gyms. There was evidence that there was HSE guidance on swimming pool operations, but there is not for other facilities and it was felt that this would help the industry, particularly given the proliferation of such gymnasia in recent years, if there was formalised national guidance on risk assessment in fitness centres and gyms. ”

    Source location

    ANTHONY STEPHEN CLEVELAND · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026